Patient Safety Watch: Maternity services need change now, not in 2030

Good afternoon and welcome to this fortnight’s edition of the Patient Safety Watch newsletter.

National maternity investigation – 14 trusts named

The government has published the rapid national maternity and neonatal investigation’s full terms of reference, along with the names of the 14 trusts that will be the focus of local investigations. These trusts are:

• Barking, Havering and Redbridge University Hospitals Trust;
• Blackpool Teaching Hospitals Foundation Trust;
• Bradford Teaching Hospitals FT;
• East Kent Hospitals University FT;
• Gloucestershire Hospitals FT;
• Leeds Teaching Hospitals Trust;
• Oxford University Hospitals FT;
• Queen Elizabeth Hospital King’s Lynn FT;
• Sandwell and West Birmingham Hospitals Trust;
• Shrewsbury and Telford Hospital Trust;
• Somerset FT (in relation to Yeovil District Hospital);
• University Hospitals of Leicester Trust;
• University Hospitals of Morecambe Bay FT; and
• University Hospitals Sussex FT.

As previously confirmed, Baroness Valerie Amos is leading the investigation, supported by a team of expert advisers.

My views?

The clarity of the terms of reference and Baroness Amos’s appointment as chair are hugely encouraging. As someone who has been following maternity safety’s progress for a long time, the Amos investigation feels the best opportunity to drive meaningful improvements in maternity safety for many years.

However, the task ahead for her will not be easy. The timescales – originally to complete by December, now initial recommendations by December, with full publication by spring – feel incredibly tight.

Families aren’t united either. Some say only a statutory public inquiry can deliver true accountability and have been sharply critical of the current process. Others – me included – worry that statutory inquiries take years and would achieve little. Sir Simon Jenkins once called them “slow journalism for rich lawyers”. He wasn’t wrong. Families and those currently using maternity services deserve change now, not in 2030. The Amos investigation feels like the right plan, but it will need the right support, resources and time to succeed.

Leeds families call for full inquiry

While Leeds has been named as one of the trusts included in the Amos investigation, families from Leeds have met with Wes Streeting to push for a fuller independent inquiry there.

They make a strong case. The Care Quality Commission has rated the maternity department “inadequate”, including for safety, and previous reports have suggested that between 2019 and 2024, at least 56 babies and two mothers may have died preventably. Leeds has also hit the headlines this week after being forced to repay £5m incorrectly awarded to maternity services for declaring they met standards under the maternity incentive scheme.

In other news…

Hillsborough law finally moves forward

After decades of campaigning, the long-awaited Public Authority (Accountability) Bill – commonly known as the Hillsborough Law – has been laid before Parliament.

The new law will introduce two key principles:

• A legal “duty of candour” on public officials during inquiries and investigations, requiring full transparency and honesty; and
• Legal parity of funding so that victims and families are not outgunned by state-funded legal teams during inquests and inquiries.

While the bill still has to pass through Parliament, it has significant implications for patient safety, as it will cover healthcare-related processes and inquests.

Interpreting services in the maternity safety spotlight

A new report from the Sands and Tommy’s Joint Policy Unit highlights that women and birthing people with limited English proficiency are often denied professional interpreting support. An earlier BBC investigation found that, between 2018 and 2022, there were at least 80 cases in England where babies died or suffered severe brain injury linked to failures in interpreting.

The report calls for stronger national policy, centralised resources, accountability, and consistent feedback from parents.

Jess’s Rule: ‘Three strikes and rethink’ for GPs

Jess’s Rule – named after Jessica Brady, who died after many GP appointments failed to detect her cancer – is to be rolled out across England.

Jess’s Rule will require GPs to rethink their approach – for example, offer a face-to-face consultation, order further tests, or make a referral – if a patient has three consultations for the same or worsening symptoms without a substantiated diagnosis.

Mr Streeting said: “Jessica Brady’s death was a preventable and unnecessary tragedy. I want to thank her courageous family, who have campaigned tirelessly through unimaginable grief to ensure Jessica’s legacy helps to save the lives of others.”

Toxic culture warning from GMC

In a speech at the HSJ Patient Safety Congress, General Medical Council chief executive Charlie Massey warned of a “toxic culture of cover-up” within the NHS that was putting mothers and babies at risk.

He said the situation was “profoundly concerning,” adding fear of speaking up can lead to cover-ups and serious harm, especially in high-risk areas like maternity care.

HSSIB must keep board, Streeting told

Patient Safety Watch, alongside fellow patient safety charities Action Against Medical Accidents (AvMA) and the Clinical Human Factors Group, have written to health secretary Mr Streeting, making recommendations to help ensure the Health Services Safety Investigations Body maintains operational independence as it moves to the CQC, as proposed in the Dash review.

The letter argues HSSIB should retain a separate board and governance framework, should lay its accounts and annual report before Parliament, be able to provide evidence to MPs, and make recommendations to whoever it deems necessary, including the CQC.

The intervention follows concerns raised by Carl Macrea that the move to the CQC will “abruptly remove the health system’s nascent capacity for independent system-wide safety investigation, and will bring to an end England’s globally leading role in pioneering a model that is emulated internationally”.

Never Events Framework judged not fit for purpose

NHS England has published the detailed findings of the 2024 consultation of the Never Events Framework, showing 66 per cent of respondents believe the framework is unfit for purpose. Proposed changes include: prioritising learning rather than rigid barrier‑based definitions; focusing on events of most concern to patients; and fostering a just culture where staff feel supported to report.

This blog by NHSE patient safety director Aidan Fowler provides a useful summary of the context, findings and next steps.

Sharing some good stuff…

New paper on patient safety investigations

The new paper from the National Institute for Health and Care Research-funded response study has just been published, evaluating how the NHS Serious Incident Framework (now replaced by the Patient Safety Incident Response Framework) shaped local practice.

The paper, led by Polina Mesinioti and Carl Macrae, explores the structural, organisational and relational constraints that shaped how the previous framework was able (or not!) to achieve its objectives in enhancing learning and improvement. The authors conclude that systemic limitations of the previous framework often turned investigations into a compliance exercise, rather than supporting real improvement.

Timely lessons as PSIRF is rolled out, and a reminder of why change was needed.

League tables won’t save lives – transparency will

Finally, a share worth reading – Jeremy Hunt warns in HSJ that new NHS performance league tables risk repeating the mistakes of Mid Staffordshire, where a focus on “hitting the number” overtook safe, compassionate care. He argues instead for transparency, independent CQC inspections, and empowering local leaders to improve safety, quality, and patient experience.

That’s about all for this edition – before signing off, if you missed the Baby Lifeline National Maternity Safety Conference this week, this LinkedIn post from delegate Hannah Carr provides a great summary and the message “whether you’re a healthcare professional, policy maker, lawyer, campaigner, or parent with lived experience – together, we are ALL part of the solution” feels like a good one to end on.

Thanks for reading, and please look out for our next newsletter in two weeks’ time.

James Titcombe